Healthcare Provider Details

I. General information

NPI: 1619606571
Provider Name (Legal Business Name): NUTRIBLE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2416 SPECTRUM
IRVINE CA
92618-3138
US

IV. Provider business mailing address

2416 SPECTRUM
IRVINE CA
92618-3138
US

V. Phone/Fax

Practice location:
  • Phone: 708-502-2828
  • Fax:
Mailing address:
  • Phone: 708-502-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: KWAMANE LIDDELL
Title or Position: CEO
Credential: JD, RN
Phone: 708-502-2828